1. Center for Injury Research & Policy

2. Pediatric Injury Prevention Research: Where have we been? Where should we be going? Andrea C. Gielen, ScD, ScM Professor and Director Johns Hopkins Center for Injury Research and Policy December 2, 2009

3. Outline Pediatric injury as a public health problem Successes in pediatric injury prevention Collaborative research examples Future needs and opportunities

4. INJURY

5. Global Burden 875,000 Children and adolescents die annually 95% are from low and middle income countries Motor vehicle crashes and drowning are among the top 10 causes of death WHO launches the first “world report on child injury prevention”, December 10, 2008 http://whqlibdoc.who.int/publications/2006/9241593385_eng.pdf

6. 20% 45 Productivity losses due to death Productivity losses due to death Productivity losses due to disability Productivity losses due to disability Medical and related costs 45% 20% 35% CDC, 2006 Lifetime Cost of Injury in the US: $406 Billion For Children (0-14) $50.5 Billion Total $11.9 Billion Medical

11. Deaths are only the tip of the injury iceberg... 7,273 Deaths 136,635 Hospitalizations 11.2 Million Medical Visits 1 19 1,544 Finkelstein EA, Corso PS, Miller TR. The Incidence and Economic Burden of Injuries in the United States, New York, NY: Oxford University Press, 2006 U.S. Children Ages 0-14

13. SUCCESS

14. 1987 – 2004 Unintentional Injury Deaths, Ages 0-14, United States Source: National Center for Health Statistics. Centers for Disease Control and Prevention. National Vital Statistics System. WISQARS Injury Mortality Reports, 1987 to 2004. Hyattsville (MD): National Center for Health Statistics, 2007. Published in Safe Kids Worldwide (SKW). Childhood Injury Trends Fact Sheet. Washington (DC): SKW, 2007.

15. Type of Incident Percent Change Motor vehicle crash  32% Drowning  44% Pedestrian injury  55% Fire and/or burn injury  58% Falls  28% Poisoning  14% Firearm  74% Suffocation  28% 1987 – 2004 Unintentional Injury Deaths, Ages 0 to 14, United States Source: National Center for Health Statistics. Centers for Disease Control and Prevention. National Vital Statistics System. WISQARS Injury Mortality Reports, 1987 to 2004. Hyattsville (MD): National Center for Health Statistics, 2007. Published in Safe Kids Worldwide (SKW). Childhood Injury Trends Fact Sheet. Washington (DC): SKW, 2007.

16. Science of Injury Control 1991 1984, 1991 Haddon, W Jr: "On the escape of tigers: an ecologic note." American Journal of Public Health (1970), 60(12):2229-2234. HADDON MATRIXHostVehicleEnvironment Pre-event Event Post- event

17. Effective Interventions Discovered

19. In July 1984, Congress and President Ronald Reagan enacted legislation that set the national minimum legal drinking age to 21.

20. Not Intended for Children under 3 years

21. COLLABORATION

22. Safe Home Project A collaboration with the JH Department of Pediatrics and the Center for Injury Research and Policy Funded by the Maternal and Child Health Bureau, HRSA and private donations

23. SAFE Home Project Program Components: Pediatric Counseling Children’s Safety Center Home Visit Caregiver: Knowledge Beliefs Skills Social support Access to resources Safety Behaviors: Smoke alarms Cabinet locks [Syrup of Ipecac] Safety gates Safe hot water

24. Pediatric Counseling S olicit A dvise F ocus E ncourage Counseling Framework 5 hours, faculty led, hands- on, role plays, homework Training Program

25. SAFER Counseling Framework Solicit Information –Ask about current practices –Use open-ended questions first Advise Parent –Recommend parent correct hazard or behavior –Provide information about countermeasures Focus on Perceptions of Risk and Barriers –Educate parent about risk –Acknowledge difficulties and barriers Encourage Compliance –Acknowledge any progress parent has made toward an injury prevention goal –Reinforce parents’ intentions to adopt behaviors Review Resources and Refer –Describe retail and community options for obtaining safety products –Refer to services / agencies when available

26. Free personalized education Reduced cost safety supplies Children’s Safety Center

27. Home Visits Community health workers –Identify hazards in client’s home –Personalize education/coach on installation –Refer to the Children’s Safety Center HOME VISITS Community health workers: Identify hazards in client’s home Personalize education/coach on installation Refer to the Children’s Safety Center

28. SAFE Home Study Design COHORT 1 Baby’s Age 0-6 12-18mos. Control O O Intervention1 O EAG O COHORT 2 Baby’s Age 0-6 12-18mos. Intervention2 O EAG + CSC O Intervention3 O EAG + CSC + HV O Key: EAG=Enhanced Anticipatory Guidance; CSC=Children’s Safety Center; HV=Home Visit; O= Interviews, Audiotapes, Home Observations Study funded by MCHB, HRSA and NCIPC, CDC

29. Safe Home Findings Amount and quality of physician counseling improved Counseling led to more satisfied patients, but had no effect on safety practices Counseling and visiting Children’s Safety Center was associated with more observed safety behaviors Home visits had no added benefit Gielen et al, 2001; 2002; McDonald et al, 2003; Chen et al, 2003

31. CSC Evaluation (1997-2008) Hours..................................................M-F 11a-4p Visitors...............................................15,000 (100% adults) Average/month Sales.......................................................$350 Outreach.......................................................7 Average/year CS Loans/Sales........................................160 CS Installs/Checks……………………......198 Adapted from: Gielen, A.C., McDonald, E.M., Wilson, M.E.H., Hwang, W.T., Serwint, J.R., Andrews, J.S. & Wang, M.C. (2002). Effects of improved access to safety counseling, products, and home visits on Parents’ safety practices. Arch Pediatr Adolesc Med, 156: 33-40.

32. Impact of the collaboration…. Sustained program of services through the Children’s Safety Center Model for other Children’s Hospitals New research –East Baltimore Community –Harriet Lane Primary Care –Johns Hopkins Health Care –Johns Hopkins Pediatric Emergency Department

33. East Baltimore Community C ARE S Safety Center Partners: Baltimore City Fire Department ; Johns Hopkins Center for Injury Research and Policy; Johns Hopkins Children’s Safety Center ; Johns Hopkins Pediatric Trauma Service; East Baltimore Medical Center, Johns Hopkins Health Care; Maryland Science Center; Maryland Institute College of Art (MICA) Research Grants: Centers for Disease Control, NCIPC; National Institutes of Health, NICHD Funders FEMA BP Annie E Casey Foundation Weinberg Foundation CareFirst BlueCross BlueShield

35. Where We Go Community Events Health Fairs Religious Organizations Schools Medical Clinics Conferences Shopping Centers

36. What We Do Personalized and engaging injury prevention education Low-cost safety products Free educational materials Smoke alarm referrals to BCFD program Child safety seat installation/checks

38. C ARE S Evaluation (1/06-10/09) APPEARANCES.......400 VISITORS............ 16,403 (67% children) DISTRIBUTED....Educ’l Materials = 4407......BCFD Referrals = 856......Safety Products = 713 81/83 (98%) visitors recommend the safety center 80/83 (96%) of visitors reported learning something new C ARE S offers a new approach to disseminating information & products Adapted from: Gielen AC, McDonald, EM, Frattaroli S, et al. If you build it, will they come? Using a mobile safety center to disseminate safety information and products to low income urban families. Injury Prevention, 2009; 15(2):95-9. and Bulzacchelli M.T., Gielen, A.C., Shields W.C., McDonald, E.M., Frattaroli S. Parental safety-related knowledge and practices associated with visiting a mobile safety center in a low-income urban. J Comm Family Practice, 2009; 32(3):147-58.

39. Pediatric Emergency Department Safety in Seconds Study Aims 1.Evaluate effects of theory-based, computer- tailored intervention called Safety in Seconds, delivered in PED on car seat, smoke alarm, and poison storage knowledge and behaviors 2.Examine the role of parental anxiety and children’s reason for visit on intervention effectiveness

40. Safety in Seconds 10-12 minute assessment Personalized, tailored feedback

41. ©Johns Hopkins Center for Injury Research and Policy

42. Safety in Seconds

43. Precaution Adoption Process Model Applied to Car Safety Seats Profile 3:Use correct car seat consistently Stage 5 - Decided to Act -------- Specific plans Stage 4 - Decided Not to Act –--- Change risk-benefit Stage 3 – Undecided --------------- Personal susceptibility; precaution effectiveness Stage 2 - Unengaged by Issue --- Personal experience; significant others Stage 1 - Unaware of Issue –------- Basic information Profile 2: Have correct car seat for age / weight Profile 1: Have car seat Stage 6 – Acting ------------------ Increase self-efficacy Stage Message Concepts Profile 4: Have car seat inspected / installed by expert

44. Definitions of Behavioral Profiles and Stages Goals Behaviors* Child Safety Seat UseSmoke Alarm UsePoison Storage^ Behavioral Profile 4 Have correct child safety seat, used every time, installed or inspected by expert Change batteries at correct intervals in all smoke alarms on all levels N/A Behavioral Profile 3 Use correct type of child safety seat used every time Have a smoke alarm on every level with batteries changed in at least one Return poisons to locked place after each use Behavioral Profile 2 Have correct type of child safety seat Change batteries at correct intervals in at least one smoke alarm Keep poisons in locked place Behavioral Profile 1 Have a child safety seatHave a smoke alarmHave a locked place *Within each behavioral profile, there are different stages of readiness to adopt the goal behavior. Individuals may report that they: 1) have not heard about the need for the behavior, 2) have not thought about adopting the behavior, 3) are thinking about adopting the behavior, 4) have decided not to adopt the behavior, 5) are planning to adopt the behavior, or 6) have adopted the behavior. ^Poison storage items asked about adult prescription medications and poisonous household products such as gasoline, products containing lye such as hair relaxing products.

45. Knowledge Outcomes Child Safety Seats Best way to keep child safe State law requires Percent used incorrectly Smoke Alarms Number needed House fires leading cause How to use properly Poison Storage Best way to store Adult prescription meds Hair relaxers with lye Unsafe on high shelf

46. Evaluation Methods Randomized controlled trial Personalized tailored injury prevention report vs. Personalized child health report 901 caretakers of children ages 4-66 mos Telephone follow-up interview at 2-4 weeks

47. Figure 1. Study Design Assessed for eligibility N=1412 Excluded N=509 Not meeting inclusion criteria n=239 Refused to participate n=201 Other reasons (e.g., missed in PED) n=69 Randomized N=901 Control N=453 Intervention N=448 2-week follow-up N=375 2-week follow-up N=385

48. Sample Child Characteristics Age <1 year 25% 1-2 years 42% 3-4 years 27% 5 years 6% % Male 50% % Injury visit 28% Respondent Characteristics Relationship to child Mother90% Father 6% % Married/ Coupled30% Education < High School10% High School74% > High School15% Per Capita Income < $5,000/year64% Anxiety Mean score34.95

49. KNOWLEDGE CONCEPTS TESTED INTERVENTION GROUP, N=384 CONTROL GROUP, N=375t-test, p-value Child Safety Seats Best way to keep child safe State law requires Percent used incorrectly Mean Percent Correct (SD)51.2 (22.0)49.7 (22.8)t = 0.937, p = 0.35 Smoke Alarms Number needed House fires leading cause How to use properly Mean Percent Correct (SD)82.5 (23.6)77.6 (23.9)t = 2.82, p = 0.005 Poison Storage Best way to store Adult prescription meds Hair relaxers with lye Unsafe on high shelf Mean Percent Correct (SD)81.2 (21.6)70.7 (23.4)t = 6.44, p = 0.000 TOTAL MEAN PERCENT CORRECT (SD)72.6 (13.9)66.4 (14.8)t= 5.87, p = 0.000

50. Behavioral Outcomes Odds Ratio (95% Confidence Interval) Car Safety Seats^ Intervention vs. Control1.32 (1.03, 1.72) Smoke Alarm Use* Intervention vs. Control1.23 (.85, 1.78) Poison Storage* Intervention vs. Control1.11 (.81, 1.52) Anxiety and Reason for Visit had no independent and no moderating effect on any of the outcomes. ^Ordinal Regression Analysis; * Logistic Regression Analysis

51. Exposure to Intervention 98% remembered report 93% read at least some of report 57% read entire report 68% discussed it with family or friends Summary Exposure Variable 39% who read the entire report AND discussed it with others were considered “high exposure”

52. Exposure Analysis High exposure compared to control group were significantly more likely to use: –Car seats 1.70 (1.20-2.41) –Smoke alarms 2.07 (1.16-3.69) –Safe poison storage 2.01 (1.27-3.16)

53. Figure 2. Percent Distributions of Child Safety Seat, Smoke Alarm, and Poison Storage Outcomes by Study Group and Exposure to the Intervention % Child Safety Seat: Always using correct car seat, inspected or installed by expert Smoke Alarm: moke alarm on every level and changing batteries at correct intervals Poison Storage: Locking poisons after each use

54. Adjusting for correlates of exposure Marital Status –Significant effects of exposure remained Income –Smoke alarms, adjustment wiped out effects of exposure; neither exposure nor income sig –Poison storage, high exposure associated with safer behaviors for those with low income (OR = 2.70) –Car seats, higher income respondents more likely to achieve safer behavior in both exposure groups (OR = 2.09 for low exposure; OR = 3.28 for high exposure)

55. % Figure 3. Percent Distribution of Child Safety Seat Outcome by Study Group and Per Capita Income* *p=0.02 Child Safety Seat: percent always using correct car seat, inspected and installed by expert

56. Conclusions The needs of low income families continue to need special attention to reduce financial barriers to safety behavior Short term changes in behavior need to be examined over longer period of follow up and with observations Computer technology and tailored messages can be effectively used for injury prevention in pediatric emergency departments

57. FUTURE

58. Two of the greatest virtues in life are patience and wisdom

59. Passion “If a disease were killing our children in the proportions that injuries are, there would be a huge public outcry and we would be told to spare no expense to find the cure -- and to be quick about it. The public would be outraged and demand that this killer be stopped.” Former Surgeon General C. Everett Koop, M.D.

60. Conclusions Despite great progress, injury remains the number one health threat to children Effective interventions exist but challenges remain to wide dissemination, especially for low income families Multi-disciplinary expertise and partnerships are needed for future success Thank you!

61. References Gielen AC, Wilson MEH, McDonald EM, Serwint JR, Andrews JS, Hwang WT, Wang MC, A Randomized Trial of Enhanced Anticipatory Guidance for Injury Prevention, Archives of Pediatric and Adolescent Medicine, 155:42-49, 2001. Gielen AC, McDonald EM, Wilson MEH, Hwang WT, Serwint JR, Andrews JS, Wang MC, The Effects of Improved Access to Safety Counseling, Products and Home Visits on Parents’ Safety Practices, Archives of Pediatric and Adolescent Medicine, 156:33-40, 2002. Bishai D, McCauley J, Trifiletti LB, McDonald EM, Reeb B, Gielen AC, The Burden of Pediatric Injury in an Urban Medicaid Managed Care Organization, Ambulatory Pediatrics, 2(4):279-283, 2002. McDonald EM, Gielen AC, Trifiletti LB, Andrews JS, Serwint JR, Wilson M, Evaluation Activities to Strengthen an Injury Prevention Resource Center for Urban Families, Health Promotion Practice, 4(2):129-137, 2003. Chen L, Gielen AC, and McDonald EM, Validity of Self-Reported Home Safety Practices, Injury Prevention, 9:73-75, 2003. McDonald EM, Solomon BS, Shields W, Serwint JR, Jacobsen H, Weaver NL, Kreuter M, Gielen AC. Evaluation of kiosk-based tailoring to promote household safety behaviors in an urban pediatric primary care practice. Patient Education and Counseling, 58(2):168-181, 2004. McDonald EM, Solomon BS, Shields WC, Serwint JR, Wang M-C, Gielen AC. Do Urban Parents’ Interests in Safety Topics Match Their Children’s Injury Risks? Health Promotion Practice, 7(4):1-8, October, 2006. Trifiletti LB, Shields WC, McDonald EM, Walker AR, Gielen AC. Development of Injury Prevention Materials for People with Low Literacy Skills, Patient Education and Counseling, 64(1-3): 119-27, May, 2006. Gielen AC, Triflietti LB, McDonald EM, Shields WC, Wang MC, Cheng JU, Weaver N, Walker A, Using a computer kiosk to promote child safety: Results of a randomized controlled trial in an urban pediatric emergency department, Pediatrics, 120(2): 330-339, 2007.